Billing & Insurance Procedures Flashcards
7 cards from real CDC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Billing & Insurance Procedures flashcards as text
A claim is denied with the reason 'procedure not a covered benefit.' What is the most appropriate next step?
Answer: Review the patient's policy to confirm the denial is accurate, then appeal if warranted
The coder should verify the denial reason against the patient's actual policy language before deciding to appeal or write off, ensuring accurate billing.
Under HIPAA, the standard electronic transaction code set for dental claims is:
Answer: X12 837D
The X12 837D (Dental) transaction set is the HIPAA-mandated standard for electronic dental claim submissions.
A patient's plan pays 80% after the deductible for basic services. The allowed fee for a restoration is $200 and the annual deductible of $50 has not been met. How much does insurance pay?
Answer: $120
After applying the $50 deductible, the remaining $150 is subject to 80% coverage: $150 × 0.80 = $120.
Which term describes the provision that requires a patient to use in-network providers or face reduced or no benefits?
Answer: Network restriction / closed panel
A closed-panel or network-restriction provision limits coverage to in-network providers, reducing or eliminating benefits for out-of-network care.
A dental office submits a claim for D2750 (porcelain-fused-to-metal crown) but the insurer pays as if it were D2710 (resin-based composite crown) due to a 'least expensive alternative treatment' clause. This is called:
Answer: Downcoding
Downcoding occurs when the insurer reimburses at a lower code than what was billed because the plan only covers the least expensive treatment alternative.
What information is required in Box 35 of the ADA Dental Claim Form?
Answer: Remarks or special conditions
Box 35 of the ADA Dental Claim Form is reserved for remarks, special notes, or conditions relevant to the claim.
Which of the following is an example of unbundling in dental billing?
Answer: Billing D4341 and D4342 separately when a full-mouth debridement D4355 was performed
Unbundling is billing multiple separate codes for a procedure that should be reported under one comprehensive code, such as using D4341/D4342 when D4355 applies.